Workers' Compensation
77 Pa.C.S. §§1, et seq.
Workers' compensation is similar to unemployment compensation, in its insurance nature. It insures against lost income from work loss, and pays health care costs for disabilities caused by "on-the-job" injuries. It is even more like "traditional" forms of insurance, because employers normally purchase a workers' comp policy from a workers' comp "carrier" (but have an option of being "self-insured").
It differs from some other traditional kinds of insurance in that it is a disability insurance policy that Pennsylvania law requires all employers to carry, for virtually all employees (managerial employees can opt out of the "policy"). And it is unlike unemployment insurance, in that employers must pay the full cost of the insurance.
An employee will be entitled to workers' compensation benefits for disabilities arising from injuries caused by the employee's work, and occurring within the course and scope of his/her employment. "Wage loss" benefits cover a portion of lost income during a work-related disability. Medical benefits pay for all health care costs generated by the injury, whether or not a work injury results in time off work. For example, an employee that suffers a relatively minor work injury and is still able to work, will still be entitled to have his/her medical bills paid by the employer's workers' compensation policy.
For the vast majority of work injuries, entitlement to benefits is usually conceded by an employer, because it is usually obvious when an injury is "work-related." In these cases, an informal claim, timely filed according to a company's work rules, will usually result in the prompt issuance of a "Notice of Claim Payable," and the prompt commencement of benefits.
However, there are a variety of situations that may justify an employer contesting a claim for workers' compensation benefits, when the employer believes that an injury and/or resulting disability do not meet one or more of the legal requirements for entitlement to benefits. For example, an employer may have reason to believe that a particular injury is not work-related because it occurred during an optional company picnic, for example. Or, an employer may have reason to believe that even though the injury occurred "at work," the injury is a spontaneous recurrence of a prior, non work-related injury, and therefore non-compensable, under the workers' compensation law.. In these cases, a notice that a claim is being contested, which contains a reason for the contest, must be issued promptly by the employer or the employer's workers' comp insurance company. If the employee disagrees with the employer's decision to contest the claim for benefits, he may appeal the decision, to the Bureau of Workers' Compensation division of the Department of Labor and Industry. The claim will be assigned to a workers' compensation judge, who will oversee the processing of the claim.
The workers' compensation judge will take testimony during one or more (usually more) hearings; receive and review documentary evidence (such as medical records submitted by both parties); and issue a decision after all the evidence is in. Parties may appeal an adverse finding to the Workers' Compensation Appeals Board; then to Commonwealth Court; and ultimately (though rarely) to the PA Supreme Court.
Unlike unemployment compensation claims, contested workers' compensation claims are invariably complex cases involving not only legal issues, but invariably involving often complex medical issues. It is therefore highly advisable that a claimant seek legal assistance, if it becomes necessary to appeal a claim that is being contested by an employer, particularly since virtually all employers and/or their workers' comp carriers will employ an attorney to defend against such claim.
If a claimant decides to appeal an employer's denial of workers' compensation benefits, it will be helpful to both a claimant and his/her future attorney for the claimant to go into a first consultation with a basic understanding of the claim process. This will allow a more productive first meeting, by avoiding the necessity of the attorney explaining "the system" and claims process to his/her new client. Keith Kendall, P.C. therefore offers a videotape that provides workers' compensation claimants with a good working knowledge of the law and the claims process.